The hand is capable of coordinated activity finer than the eye can direct. With the aid of magnification, the true capability of the hand can be exploited. As a tool for the plastic surgeon, microsurgery has allowed reconstructions that had been merely not feasible before. However, microvascular totally free tissue transfer is not a technique for the occasional microsurgeon. The catastrophic complication of flap failure looms over every microsurgical case; as a result, expertise in the execution of a free flap as well as its postoperative surveillance is key to a effective outcome.
Expertise has shown that flap loss is a preventable complication and that elective microsurgery ought to have a failure rate of much less than 2%. Most instances of flap loss are technical in nature. The fault might lie in the choice of flap, the harvest of the flap, preparation of donor vessels, insetting of pedicle or microsurgical method. In general, it is best to think of all possible errors as additive in the procedure of thrombosis. Failure will happen if the procoagulatory factors outweigh the intrinsic capability of the vessels, in particular intact and uninjured intima, to stop clot formation.
The first step for success in microsurgery is flap option. The most important determining factors for flap option should be the surgeon's expertise and the goals of reconstruction. In general, each surgeon ought to identify at least four flaps they feel comfy with. These flaps should include a bulky muscle flap, a bulky fasciocutaneous flap, a thin fasciocutaneous flap, and a bone flap. With this armamentarium, the reconstructive surgeon will have tools that can be applied to most situations. By limiting himself to a little number of flaps, more expertise can be obtained with each one.
This increased expertise translates to increased success. It's not advantageous to explore every novel flap that is reported, as this dilutes the experience and increases the chance of failure. With increasing experience with each flap comes increasing success along with a lower failure rate.
This doesn't imply that specific flaps might not be beneficial over other people in certain situations. There's no doubt that the donor properties of a latissimus dorsi flap differ from those of the gracilis flap and that each might be a better option for a specific patient. However, the patient is best served with effective reconstruction. If there's significant benefit in a flap where the surgeon has no experience, the surgeon ought to consider referral or should seek extra training in order to add that flap to his or her armamentarium. This may include time in a cadaver lab or observing a surgeon with a particular skill.
Having mastered the tools of reconstruction, the surgeon ought to judiciously think about the requirements for reconstruction. Bulky muscle flaps are best for contaminated defects and bony injuries with high risk for infection. Thick fasciocutaneous flaps are helpful for contour and shape reconstruction. Thin fasciocutaneous flaps offer stable, noncontracting coverage. Bone flaps offer structural integrity.
Certain principles, however, hold true despite the flap chosen. While harvesting a flap, the pedicle should be carefully dissected with as much length as feasible. It is important not to limit the pedicle length to the anticipated need, but to harvest the maximum that can safely be obtained. It's much more advantageous to discard unneeded length than to find oneself requiring more pedicle length. Vein grafts should be avoided unless completely necessary.
While harvesting the flap and dissecting the pedicle, probably the most typical mistake is damaging the vessels. Forceps ought to only touch the adventia and never purchase the vessel as the intimal layer is extremely fragile and effortlessly fractured or crushed by manipulation. Any grasping of the vessels will trigger damage to the intima which increases the likelihood of clot formation. This intimal injury leads to platelet deposition and thrombosis as the injured endothelial cell layer loses its natural thrombolytic properties.
Division of the pedicle should be reserved until the last possible moment. Prior to division, the donor vessels should be dissected, isolated, prepared and positioned for the anastomosis. It is helpful to mark the vessels in their natural state to assure that they are not twisted when transferred to the recipient website. Prior to division, the artery should be occluded first, followed by the vein. This will steer clear of excess blood pooling in the flap. Immediately after the flap is removed, one can think about cooling the flap with chilled saline as this decreases the metabolic activity of the tissue and allows the luxury of a longer ischemic time.
There's seldom a need to separate the artery and vein within the pedicle for anything more than a minimal distance. The only exception is the case where the recipient vessels are not paired. The vessels ought to not be skeletonized until they are brought to the recipient site and carefully prepared under the microscope. Any branches within 2 mm of the anastomosis are greatest sutured closed with microtechnique to avoid blood pooling near the anastomosis.
Preparing the recipient website mirrors the harvest of the flap. Vessels should be chosen that are simple to make use of and of the largest caliber available. They should be expendable when possible and have sufficient length. Again, care should be taken in the preparation of the vessels. They ought to not be extensively manipulated or injured. They should only be skeletonized for 2-3 mm around the anastomotic site, and this should be done under the microscope.
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